B-2017-1997 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-1997
18700 NEWSOM AVE CUPERTINO,CA 95014-3855(375 30 005) NILSENE BUILDER
INC
CUPERTINO,CA 95014
OWNER'S NAME: LUI PAK NIN AND WONG JESSICA PUI-YEE TRUSTE DATE ISSUED: 11/17/2017
OWNER'S PHONE: PHONE NO:(408)993-1229
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class B Lic.#1019073
Contractor NILSENE BUILDER INC Date 10/31/2018 X BLDG X ELECT PLUMB
MECH X RESIDENTIAL_COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing,
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
(N)TEMPORARY POWER POLE(100 AMP)
I hereby affirm under penalty of perjury one of the following two declarations:
t, I have and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the
# performance of the work for which this permit is issued.
og. I have and will maintain Worker's Compensation Insurance,as provided for by •
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$600.00
APPLICANT CERTIFICATION
I certify that'I have read this application and state that the above
information is correct."agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 375 30 005
representatives of this city to enter upon the above mentioned property for
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations p' th Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED;INSPECTION.
,:'nature Date 11/7/2017 Issued by:Jasmine Archbold
Date: 11/17/2017
OWNER-MADE ECLARATION
.1 �
I hereby affirm that.I,am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
a. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:11/7/2017
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
• Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and'will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534..I will
permit;is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
material. Additionally,should I use equipment or devices which emit hazardous
shall not employany person in any manner so as to become subject to the
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption;I become subject to the Worker's Compensation provisions of the the Health&Safety Cod: S tons 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall SFr ,
be'deetned revoked.
aff," r or authorized agent: ., t ;
• APPLICANT CERTIFICATION e: 11/7/2017
I certify that I have read this application and state that the above information is 1 N TR IMP►L Di► A EN Y
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a cYrruction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permitisissued(Sec.3097;Civ C.)
to enter upon,the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records..
Licensed
Signature Date 11/7/2017
Professional
CONSTRUCTION PERMIT APPLICATION
`, ' 'T COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
: 4
s5)'.', 10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 •
`r�TAas.� C� t 1 -
,a, (408) 777-3228 • building@cupertino.org PEMIT B- A
. CUPERTINO REV# DEFE
❑ NEW CONSTRUCTION ❑ADDITION ❑ALTERATION ❑T.1. ]MEP ❑RE-ROOF ❑SWIMA'fING POOL/SPA
PROJECT ADDRESS l APN X
. \g -00 /✓ewScrr1 A v7
OWNER NAME
STREET ADDRESSSCA, vt.r CITY, STATE,ZIP
CONTRACTOR NAME ❑OWNER-BUILDER COMPANY NAME LICENSE NUMBER LICENSE TYPE
STREET ADDRESS „, CITY,STATE, ZIP • I
\ �ee n/e„c Sem A✓e CUPPIi-t''nC
E-MAIL �� PHONE BUS.LIC X
ngi „C(ao �,mo.0 .Cem 11ag—L-IQQ —6'5e 5 •
0 ARCHITECT ❑OWNER.❑OWNER AGENT 0 CONTRACTOR AGENT ENGINEER 0 DEVELOPER 0 TENANT . '
CONTACT NAME E-MAIL
MO C—' MIISeel e4-1e._al. m0‘'ti1. c M
STREET ADDRESS\ #216 CITY,CU PG Z(IP'c1 did PHOge e—o4 k^ -66n 9
21cs6c 140 w,Ps4ec,l gra. r
DECRIPTON .
\0 A 01 W -7f' 4 fort pc t
•
•
❑SINGLE-FAMILY/DUPLEX 0 MULTI-FAMILY 0 INDUSTRIAL ❑COMMERCIAL - I
EXISTING USE EXISTING SF NEW FLOOR SF PORCH SF DECK SF DEMO SF STORIES TOTAL NET SF USE TYPE OCC SQ.FT. VALUATION(5)
REMODEL REMODEL KITCHEN REMODELOTHR ' GARAGE ❑ATTACHED
BATHROOM SF SF SF SF 0 DETACHED
EXISING ❑YES EICHLER ❑ YES SECOND STORY ADDITION O YES
FIRE SPRINKLERS 0 NO 0 NO NO
DWELLING SECOND DWELLING ❑yEs 0 ATTACHED❑DETACHED OTHER
UNITSX UNITADDITON: ❑NO 5F ,
POOLS 0 FIBERGLASS ❑VINYL-LINED 0 GUNITE 0 PREFABRICATED
POOL-SF SPA-SF I SPAATTACH ED ID YES ❑ NO I TOTAL-SF
RECEIVED BY: TOTAL VALUATION:
Conm:errial or Multi-Family Buildings with Public 5win1 vinp Pools requires Department a(Eevironmenfal Heath anvraval joa
RE-ROOF EXISTING ROOF TYPE: E BUILT-UP ROOF❑ASPHALT SHINGLES WOOD SHAKES WOOD SHINGLES❑TILE OTHER(SPECIFY) '
REMOVE/REPLACE❑NO IF NO PLYWOOD ❑t'f” ❑3/8" 'PLYWOOD TYPE: PITCH: ROOF CLASS
DYES I4 OF LAYERS _ THICKNESS❑5/8" OTHER DOSS 0 CDX OTHER :12 A
PROPOSED ROOF TYPE:❑BUILT-UP ROOF ❑ASPHALT SHINGLES 0 WOOD SHAKES,❑WOOD SHINGLES 0 OTHER -
*Provide a signed copy of the Cupertino's Tear-Off Policy SF of SQUARES
By my signature below I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I
have read this application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree
to comply with all applicable local ordinances and to _ laws relating to building construction. I authorize representatives of Cupertino to
enter the above-identified property for inspection p rp e I acknowledge and authorize all information contained on this application form
to be made available for public record. M.-- t �`
Signature of Applicant/Agent: Date:
SUPPLEMENTAL INFORMATION REQUIRED
*New SFD/Second Dwelling Units/Multifamily Dwellings:A Demolition permit is required prior to issuance of a building permit for all new constriction.
*Commercial Buildings: Provide a completed Hazardous Materials Disclosure form if any Hazardous Materials are being used as part of this project.
'Copy of Planning Approval Letter or•Meeting with Planning prior to submittal of Building Permit application. •
•
"HOA-Provide a letter of approval from the Home Owner's Association
Bldg,4pp_2017.doc revised 08/01/17